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Call To Arms: Africa to Asia, Caribbean
to Kazakhstan, An Explosive Epidemic
Said To Threaten Backbone of Civil Society
A Demographic Catastrophe

August 2000

"I'm not someone who blames the West for everything. I do believe that the great moral test of our time is how the rich countries respond to the AIDS crisis. But AIDS has not been high on the agenda of the highly affected countries, so this is a ... failure for the countries of the north and for the countries of the south. At the moment, a total of $300 million is being spent on prevention and awareness for the whole continent [of Africa]. We need $2 billion to do this."

Peter Piot, New York Times Magazine, 6/4/00

"Technological leader and beacon of hope for much of the world, the United States has been the meanest donor of all. It musters a trifling $5 per American each year in budget assistance for the poorest countries."

Jeffrey Sachs, The Economist, 6/24

Ten years ago, when the AIDS death toll in the United States crossed 100,000, few paid heed to a grim prediction by the World Health Organization (WHO) that "by the year 2000, 40 million persons may be infected with HIV." In the rich world, AIDS was seen as a serious but smallish disease, restricted to gay men, drug users, hemophiliacs, and the innocent offspring of all three. In the developing world, just a few courageous voices were warning about the silent spread of a deadly new plague.

Today, WHO's grim prediction has come true. Africa is in crisis. In some countries, a quarter or more of the adult population is infected. Millions have died, and millions more will follow, leaving their societies trapped in poverty, burdened with a generation of orphans, and facing demographic catastrophe. The grim statistics are not confined to Africa. Asia and the Caribbean face explosive HIV epidemics, while the nations of the former Soviet empire peer over the precipice of drug addiction, untreated sexual diseases, and unchecked HIV spread. HIV is out of control, and finally the world has begun to take notice.

In January 2000, the United Nations Security Council held a special session in which for the first time it identified a disease-AIDS-as a global security threat. Some American cynics have mocked this move as domestic political theater, but no serious observer denies that HIV is undermining nations and economies. HIV kills young people in their most productive years. In a growing number of countries, workers, teachers, nurses, civil servants, and others will perish in astonishing numbers. The backbone of civil society is threatened in many nations, and the threat remains uncontrolled.

The security threat is real, but only half the story. HIV began as an obscure simian virus in equatorial Africa in the first half of the twentieth century and, within fifty years, had spread throughout the world. The forces that brought HIV to America in the 1970s-world travel, globalization, and urbanization-are accelerating. One need only look at the number of variant strains of HIV-1 spreading worldwide, at the outbreak of West Nile Virus in the Northeast, or at the number of HIV-2 cases now emerging in New York and other gateway American cities, to see how the forces of globalization are adding new ingredients to the world's microbial soup. When HIV remains unchecked in large regions of the globe, as it does now, no country is safe, including America. Fighting AIDS abroad is in America's own interest.

In response, the U.S. government now proposes new initiatives to fight the global spread of AIDS. TAG welcomes them. But the U.S. has conducted global AIDS programs for more than a decade, and related international health programs for even longer. Any new AIDS funding builds on this foundation. Yet no analysis exists of the present U.S. role in the global AIDS pandemic. Without review and evaluation, any new programs run the risk of being scattershot and ineffective. In other words, recent good intentions may, without good planning and evaluation, lead nowhere. If the U.S. cannot summarize its current programs accurately, how can they grow effectively?

This report is a first, imperfect documentation of what the U.S. government spent in 1998 on international HIV programs. We hope this analysis can serve as a foundation, a basis for decision-making, a hopeful call to action. Inside, we describe what the U.S. government has done, so others may better answer what can and should be done. We hope others in the developed, democratic world take this report as a model to press for more and better responses from their governments. We hope people in poorer countries will use this report to navigate the U.S. government and become full partners with the American effort. (The complete international report can be obtained by calling the TAG office, 971-9022, or by retrieving it from our website.)

Information from U.S. agencies ranged from clear to chaotic to non-existent. The lack of clear information hampers not only this analysis but any attempt to understand and evaluate the successes and limitations of the U.S. program. If the program cannot be defined, how can anyone know if it succeeded? The findings in our report should be viewed as a first step, an exploration of the U.S. government's emerging response to the global AIDS pandemic, and a call to action for the future.


Summary Findings

Three U.S. government agencies formed the core of the American response to the global AIDS pandemic in 1998. The U.S. Agency for International Development (USAID) spent $123.7 million on international AIDS programs in 1998, including a $23 million contribution to the United Nations AIDS program, the single largest component of that international agency's budget. The National Institutes of Health spent $52 million on international AIDS research projects in 1998. The Centers for Disease Control spent $9 million.

Overall, the U.S. government supported 463 HIV/AIDS projects in 79 developing nations: 28 African countries (36% of the budget), 20 Asian nations (15% of the budget), 19 Latin American and Caribbean countries (12% of the budget) and 12 Eurasian countries (1% of the budget). The U.S. also supported 53 projects that were global, multi-region, or undefined in scope, reaching many countries across regions. These global programs accounted for approximately 34% of the U.S. funds.

In our report, we describe the U.S. international HIV/AIDS 1998 program activities in nine categories. The largest (31% of the total budget) was the development of health systems infrastructure by the U.S. Agency for International Development in 36 countries. USAID supported HIV prevention programs (20% of the budget) in 37 countries. Support for the United Nations AIDS Program took up 12% of the total budget. NIH-funded academic research projects (11% of the budget) in 37 countries. All three agencies funded epidemiology and surveillance projects (8% of the budget) that operated globally and in 12 countries. The National Institutes of Health (NIH) supported a vaccine discovery program (7% of the budget) in 10 countries. NIH trained researchers (5% of the budget) from 43 countries. USAID developed community and governmental leadership (3% of the budget) in 29 countries. NIH supported reference labs and other research resources in the U.S. (3% of the total budget) that served global needs.

Other U.S. agencies played a role in the global AIDS response, but that role is small and, in some cases, unclear. The most important example is the Department of Defense (DOD), which maintains an international HIV research program. (DOD officials refused to cooperate with the preparation of this report.) Other agencies with an international presence are the departments of State, Labor, and Commerce. The limited information we could obtain about these programs is summarized in our report but is not otherwise included in the analysis.

The U.S. international HIV program is not direct aid to foreign governments or agencies; rather, it included the direct overseas programs of 12 divisions of the U.S. government, support for the United Nations, and contracts and grants to 48 universities or nongovernmental organizations (NGOs), all but three of which are located in the U.S.

Most contracts and grants in the U.S. international program were concentrated at 17 academic or non-governmental organizations (16 American and one British). These organizations all received more than $1 million from the U.S. government for international HIV programs, and collectively received 43% ($79.8 million) of the total program. The single largest contractor was Family Health International, a Virginia-based NGO, which alone received $25 million. Johns Hopkins University received $4.4 million, more than any other academic institution.

The U.S. international AIDS program is a small part of larger initiatives in global health and research. In 1998, the NIH international AIDS research program was 2% of the $1.8 billion AIDS research program. CDC's international AIDS program was less than 1% of its overall AIDS program. Even at USAID, AIDS was just a fraction of that agency's development agenda. AIDS programs accounted for less than 9% of USAID's entire budget, and less than 22% of its health programs. In countries where USAID operates missions, AIDS funding typically never exceeded 5% of the total mission budget. In those few cases where the relative portion of AIDS funding was higher at a USAID mission, the absolute funding for AIDS and other activities was generally low. As a portion of the U.S. domestic $8.7 billion AIDS budget, the entire U.S. international program barely reached 2%.

While the U.S. is the largest contributor of AIDS-related development assistance in absolute terms, other rich countries spend far more when population and gross national product are taken into account. The Netherlands, Norway, Sweden, Denmark, Australia, Canada, the U.K. and even Belgium contributed more on this adjusted basis. These comparisons, however, do not include funding for AIDS research-an area in which the U.S. clearly outspends all other countries. These two factors should be considered when comparisons are made.

This year, the U.S. proposed its new Leadership and Investment in Fighting an Epidemic (LIFE) initiative. Funded with $100 million in new or redirected resources (opinions vary), LIFE will reprogram $54 million for international AIDS activities to USAID, $26 million to CDC, and $10 million each to the Departments of Defense and Labor in fiscal year 2001. While supportive of this new initiative, we would support inclusion of new resources for NIH as well, which has a substantial ($53 million) investment in international research, as well as significant expertise and infrastructure. The LIFE initiative represents a minimum acceptable increase in U.S. support for international HIV/AIDS activities and we hope resources continue to increase substantially.

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